Provider Demographics
NPI:1598905929
Name:PETERSON, JOHN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8472 OAK FARMS DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-1860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12427 S 4000 W
Practice Address - Street 2:STE 200
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-254-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7020843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist